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NHS
CANCER
                                   NHS Improvement



DIAGNOSTICS

              Continuing to Improve
HEART
              Cardiac Services
              Heart Improvement Programme
              National Project Summaries 2009/10
LUNG




STROKE
Continuing to Improve Cardiac Services - National Project Summaries 2009/10
Continuing to Improve Cardiac Services   |   3




Contents
                                Foreword                                                4



“
So far, improvements in
the pathway and transfer
arrangements have saved
                                Introduction

                                NHS Health Check
                                                                                        5

                                                                                        7

the equivalent of some 959      Atrial fibrillation in primary care                     9
NHS beds each year across
England. We know that           National roll-out of primary PCI for ST
there is a lot more that can    segment elevation myocardial infarction                 11
be done to take this further
saving the NHS a great deal     Arrhythmia - cardiac devices
                                and inherited cardiac conditions                        13
of money and patients a
great deal of stress and
                                Sustaining cardiac pathways -



         ”
worry.
                                cardiac surgery                                         14

Professor Roger Boyle CBE,      Heart failure                                           17
National Director for
Heart Disease and Stroke
                                Cardiac rehabilitation                                  20
Signpost to Improving Cardiac
Inter Hospital Transfers,
Heart Improvement Programme,    NHS Improvement System                                  22
(2007)
                                Resources                                               23
4 | Continuing to Improve Cardiac Services




Foreword
                              In the 10 years since the launch of the National   But there is more to be done - there are still
                              Service Framework (NSF) for Coronary Heart         unnecessary waits for transfer to surgical and
                              Disease in 2000, we have seen a substantial        specialist centres. The recent National Audit of
                              improvement in cardiac services which has led      Cardiac Rehabilitation (NACR) figures show
                              the way in the NHS for improved and equitable      that uptake remains low and that
                              access to services. Mortality rates have fallen    commissioning and provision of adequate
                              quickly and health inequalities have narrowed.     cardiac rehabilitation remains a challenge; the
                              Waiting times for diagnosis, heart surgery and     provision of integrated heart failure services
                              angioplasty have fallen dramatically and the       across the whole patient pathway is also in
Professor Roger Boyle, CBE    care of patients with acute coronary syndromes     need of focused attention.
National Director for Heart   has changed dramatically. We are operating
Disease and Stroke,
                              on more people with higher levels of risk and      As we move forward, we face an even bigger
Department of Health
                              co-morbidity, whilst delivering better outcomes.   challenge to continue to provide high quality
                              We have also witnessed opportunities for           care while at the same time delivering it much
                              health care professionals to widen their skills    more efficiently. This will be the biggest
                              and expand their roles and scope of practice.      challenge that has faced us in the history of
                                                                                 the NHS.
                              The progress and improvements made over the
                              last 10 years to achieve the NSF have been         I hope you will join me in celebrating all that
                              made possible by a collaborative effort by all     we have achieved together at the NHS
                              organisations and staff across the NHS. The        Improvement – Heart Conference which marks
                              CHD Collaborative started in 2000 with just 11     the 10th anniversary of the National Service
                              local sites, moving quickly to 30 collaboratives   Framework. The following pages outline for
                              and was followed by the development of             the wider NHS the range of national areas of
                              clinical networks. Today, cardiac networks         work delivered by NHS Improvement – Heart,
                              continue to be uniquely placed to assist with      that have helped increase productivity and
                              the delivery of the quality agenda by linking      efficiency in services and have improved the
                              clinicians, managers and commissioners             experience for cardiac patients and staff.
                              together in every aspect of the patients’
                              journey through primary, secondary and tertiary
                              care. They continue to be well positioned to       Professor Roger Boyle CBE
                              reflect local relationships between clinicians     National Director for Heart Disease
                              across organisational boundaries to further        and Stroke, Department of Health
                              develop safe and effective pathways of care for
                              patients by providing an opportunity for
                              clinicians and managers to work together on
                              the redesign and commissioning agenda.

                              The work of NHS Improvement and its
                              predecessor organisations has been a constant
                              source of support to these improvements and
                              pivotal in the development of systems that
                              deliver high quality care.
Continuing to Improve Cardiac Services   |   5




Introduction
                              This document details the areas that the          Moving on to next year, the new priorities
                              Heart Improvement Programme has been              have already been agreed. Inevitably, given
                              working on during 2009/10, briefly                the financial context in which we are now
                              describing the various ideas that have been       working, there is a focus on productivity, but
                              tested by commissioners and providers across      that does not mean that quality of care is
                              England. The priority areas were agreed at        relegated to second place and we look
                              the start with the policy team with input         forward to expressions of interest from
                              from the cardiac networks. The networks           anyone who is committed to developing new
                              were then asked to put forward proposals          ways of working and improving services for
Mark Dancy                    for work in these areas and selected projects     patients.
Consultant Cardiologist and
National Clinical Chair,      were facilitated both by the networks and by
NHS Improvement - Heart       the national team. We chose projects that         Priority projects for 2010/11
                              had clear objectives and scope, were
                              achievable in a manageable timeframe              Cardiac rehabilitation
                              (usually less than two years), and would          The work will aim to increase the provision
                              produce new ways of working that could be         and uptake of cardiac rehabilitation (CR) by
                              adopted by others.                                working with the Department of Health to
                                                                                develop a commissioning pack designed to
                              This summary document is not intended to          help PCTs and providers improve the
                              describe the individual projects in detail, but   specification, commissioning and potential
                              further information is easily available from      procurement of CR services. The
                              the contacts given in the text. I would           commissioning pack will form the main tool
                              encourage anyone interested in carrying out       in a programme of improvement work and
                              similar work to get in touch with the teams       its roll out and implementation will be
                              who have been involved in these priority          supported by NHS Improvement.
                              projects as they have invested considerable
                              resource learning what works and what             Heart failure
                              doesn’t and that can save a lot of time and       As highlighted in ‘NHS 2010 - 2015: From
                              anguish.                                          good to great’ (2009,) the main aim of this
                                                                                work will be to improve clinical outcomes
                              As you will see from the descriptions of the      and patient experience by decreasing the
                              projects, there have been some very               number of emergency admissions,
                              successful initiatives which have measurably      readmissions and in-patient bed days
                              improved the quality of care for patients and     through optimising care for patients with
                              carers, and I congratulate the teams on their     heart failure. The scope will include early
                              hard work and perseverance. If others can         accurate diagnosis, optimising management,
                              take these ideas and develop them in their        integrated care, the role of the care
                              own localities, the potential health gain is      coordinator and end of life care.
                              considerable.
6 | Continuing to Improve Cardiac Services




                           Reducing avoidable delays in non
                           elective inpatient management                     Cardiac devices
                           This initiative builds on lessons learned in      This initiative will continue to engage with
                           elective inpatient management for surgery         network and provider device clinical leads to
                           and revascularisation and in previous             review local service provision and address
                           interhospital transfer studies. The work aims     equity of access in cardiac networks. This will
                           to improve clinical outcomes and patient          be underpinned by supporting the device
                           experience by decreasing in-patient bed           survey team to drive up data quality and
                           days through optimising care for patients         submission timeliness whilst expanding the
                           with acute coronary syndromes (ACS),              functionality of existing data sources for
                           arrhythmias and those requiring cardiac           clinical users for clinical audit and
                           surgery.                                          commissioning purposes.

                           Atrial fibrillation                               NHS Health Check
                           This work will build on existing priority         Work to support the implementation of this
                           project work on atrial fibrillation (AF) with a   major initiative will move from NHS
                           view to accelerating progress, sharing            Improvement to NHS Diabetes and Kidney
                           lessons learned and extending and                 Care from May 2010. NHS Health Check
                           embedding the use of tools, methodologies         remains a key policy initiative for the
                           and resources for AF developed and tested         prevention of cardiovascular disease and
                           during the pilot and prototype phases. The        work in cardiac and stroke networks on this
                           focus will be on raising awareness of AF,         important area will continue.
                           training and education of clinicians in
                           detection and treatment, exploring all            Some of the projects from this year are still
                           opportunities for screening for AF and            running, but networks will be looking out for
                           ensuring anticoagulation and treatment are        people who think they may be able to
                           optimised in both primary and secondary           contribute their ideas in the various project
                           care. A substantial reduction in the number       areas for 2010/11 and if you think you might
                           of resulting strokes is anticipated and the       want to join us I would encourage you to
                           work will contribute considerably to the          speak to your network as soon as possible
                           quality and productivity challenge.               even if only to discuss your proposal
                                                                             informally.
                           Primary angioplasty (reperfusion)
                           This work will involve a continuation of
                           the primary percutaneous coronary                 Mark Dancy
                           intervention (PPCI) project workstream with       National Clinical Chair
                           implementation across England and the             NHS Improvement - Heart
                           development of a sustainable service across
                           the whole patient journey. This will include a
                           focus on the adoption of robust cardiac
                           rehabilitation pathways and an emphasis on
                           the improvement of the data quality for local
                           and national audit.
Continuing to Improve Cardiac Services   |   7




NHS Health Check
Aims of the project
To support the successful
implementation and delivery of the
NHS Health Check programme - a
systematic and integrated programme
of vascular risk assessment and
management which will offer
preventative checks to all eligible
people aged 40-74 to assess their risk
of vascular disease (heart disease,
stroke, diabetes and kidney disease)
followed by appropriate management
and interventions. The proposals for the
NHS Health Check programme
(formerly vascular checks) were set out
in ‘Putting Prevention First’, published
on 1 April 2008 and aim to ensure
greater focus on the prevention of
vascular disease and a reduction in
health inequalities. Implementation of
this major national programme began
in April 2009 and all Primary Care         Approach taken                                the Department of Health, and to
Trusts are expected to achieve full roll   The NHS Health Check Learning                 signpost to other useful information
out by 2012/13.                            Network includes NHS commissioners            sources.
                                           and providers, independent and
Project overview                           voluntary sector organisations,               The NHS Health Check Learning
To coincide with the publication of        individuals and a wide range of other         Network website acts as a central
Putting Prevention First, NHS              stakeholders who are interested or            repository for the network and has
Improvement, in collaboration with the     involved in the implementation of the         been developed to help commissioners
Department of Health, established a        NHS Health Check, including the               and providers locate relevant resources
national Learning Network in order to      cardiac and stroke networks.                  and information to support local
learn from, build upon and share the                                                     implementation. It includes details of
learning and experience of both            The Learning Network is underpinned           national workshops as well as key
existing and emerging vascular risk        by a series of interactive workshops          guidance documents and latest news
assessment and management                  with a strong focus on sharing and            relating to the NHS Health Check
programmes across the country. The         learning and featuring presentations,         programme, a useful links section, an
Learning Network has focused on            discussions and interactive group work        expanding number of case studies, and
tackling the many challenges to            around the emerging issues and                a resource library containing
implementation and delivery of the         themes.                                       ‘documents for sharing’- to save
programme, including commissioning                                                       commissioners and providers from
and procurement, workforce capacity,       The Learning Network is also supported        reinventing the wheel.
training and education, informatics,       by the publication of a regular eBulletin
checks in community settings,              which aims to keep subscribers up to
leadership and clinical engagement         date with news and information from
and so on.                                 across the Learning Network and from
8 | Continuing to Improve Cardiac Services




 NHS Improvement has also supported           Current estimates indicate that over        Contact details
 19 carefully selected ‘test bed’ sites to    85% of PCTs in England will have
 investigate different aspects and            commenced roll out of NHS Health            Julie Harries
 models of delivery to help inform policy     Check in 2009/10 and it is likely that      Director
 and assist with the development of           the establishment of the national           julie.harries@improvement.nhs.uk
 further guidance. Funded by the              Learning Network has made a
 Department of Health, learning from          significant contribution to this in         Mel Varvel
 the test bed programme is currently          addition to tangible (figures to be         National Improvement Lead
 being shared across the Learning             confirmed) progress towards the             mel.varvel@improvement.nhs.uk
 Network, largely via the production of a     delivery of 1,000,000 checks by April
 series of practical implementation           2010 (as cited in Working Together –
 guides, the first of which was published     Public Services On Your Side published
 in November 2009.                            in March 2009).

 Results and achievements                     Next steps
 To date, NHS Improvement, alongside          The national Learning Network is set
 the Department of Health, has                to continue to support ongoing
 facilitated seven national learning          implementation and delivery though
 events attended by well over 1,000           the facilitative role played by NHS
 delegates. These national workshops          Improvement will transfer to NHS
 have generated a great deal of interest      Diabetes and Kidney Care in Spring
 from a wide range of stakeholders            2010.
 across the country and have been very
 well received and evaluated by               Supporting information
 attendees:                                   To find out more about the NHS Health
                                              Check Learning Network, and to
“ Today's workshops have been                 download any of the supporting
                                              guidance and resources, visit the
  fantastic. It's really valuable to
                                              website at: www.improvement.nhs.uk/
  hear what's happening from                  nhshealthcheck
  the centre and in other areas.”
                                              Further information on the national
 Eight eBulletins have been published to      policy can be found on the
 a growing distribution list of almost        Department of Health’s website at:
 900 people, and the website continues        www.dh.gov.uk/nhshealthcheck
 to achieve a high ‘hit rate’.
                                              Public-facing information is available on
 The first implementation guide on Point      the NHS Choices website at:
 of Care Testing proved extremely             www.nhs.uk/Planners/NHSHealthCheck
 popular and has received very positive       /Pages/NHSHealthCheck.aspx
 feedback.
Continuing to Improve Cardiac Services   |   9




Stroke prevention in primary care:
managing atrial fibrillation
Aims of the project                                                                        Key areas for piloting new
To improve quality outcomes for                                                            approaches centred on:
patients with atrial fibrillation (AF) and                                                 • Detection of AF through opportunistic
reduction in health and social care costs                                                    screening at flu clinics
by reducing their risk of stroke through                                                   • Local enhanced service (LES) schemes
service improvement to improve                                                               for detection, screening and review
detection, diagnosis and optimal                                                             of AF
therapy and management in primary                                                          • New models for anti-coagulation
care.                                                                                        services in primary and community
                                                                                             settings
Chapter Eight of the National Service                                                      • Development of tools to support the
Framework for Coronary Heart Disease;                                                        review of patients with AF, risk
Arrhythmias and Sudden Cardiac                                                               stratify for stroke and consider
Death, published in March 2005, set                                                          optimal therapy
out the quality requirements for the                                                       • Guidelines for primary to secondary
prevention and treatment of patients                                                         care referral.
with cardiac arrhythmias. In December
2008, the publication of the National                                                      All projects found the need to include
Stroke Strategy affirmed the                                                               education for professionals and
importance of this work for stroke                                                         patients around:
prevention within Quality Marker 2           This treatment is also highly cost            • Pulse palpation
‘Managing Risk’.                             effective. The treatment of AF with           • Barriers to anti-coagulation in
                                             warfarin reduces risk of stroke by              primary care
Atrial fibrillation is the most common       50-70%:                                       • ECG training and interpretation
sustained dysrhythmia, affecting at          • The estimated total cost of                 • Patient awareness.
least 600,000 (1.2%) people in England         maintaining one patient on warfarin
alone. It is also a major predisposing         for one year, including monitoring, is      Approach taken
factor to stroke, with 16,000 strokes          £383                                        These projects led by NHS Improvement
annually in patients with AF of which        • The cost per stroke due to AF is            Heart and Stroke Programmes, sought
approximately 12,500 are thought to            estimated to be £11,900 in the first        to work with primary care trusts (PCTs),
be directly attributable to AF.                year after stroke occurrence.               general practices, practice based
                                                                                           consortia (PBC) acute trusts and
The annual risk of stroke is five to six     Project overview                              voluntary organisations to address the
times greater in AF patients than in         The first phase of priority projects were     detection of atrial fibrillation, whether
people with normal heart rhythm and is       established in October 2007 and               patients were appropriately treated
therefore a major risk factor for stroke.    completed April 2009. Eighteen                with anti-coagulants and to consider
Uniquely, it also in an eminently            individual projects were established          the best pathways for managing atrial
preventable cause of stroke with a           across 15 cardiac and stroke networks         fibrillation in primary care.
simple highly effective treatment.           A variety of approaches were
                                             undertaken responding to the needs of         Regular peer support meetings were
                                             the local health communities.                 held to encourage the sharing of
                                                                                           resources, learning and collaborative
                                                                                           working to drive forward improvements
                                                                                           in care and maximise benefits.
10 | Continuing to Improve Cardiac Services




In parallel, at a national level, NHS         Based on numbers needed to treat            National Publications
Improvement has sought to achieve a           ranging from 25 to 37 (Kerr), the costs     National Stroke Strategy – Quality
consensus approach across England to          of each stroke prevented with warfarin      Marker 2: Managing Risk (2007).
the management of AF patients within          are in the range £9,500 to £14,000.
primary care with key stakeholders                                                        National Service Framework for
resulting in the publication of a             Each year appropriate anti-coagulation      Coronary Heart Disease (CHD) –
commissioning guide in May 2009 and           could prevent 4,500 strokes in patients     Chapter 8: Arrhythmias and Sudden
continues to make formal                      with AF at an additional cost of £63.5      Cardiac Death (2006).
representation to influence                   million.
amendments to the current AF                                                              Management of atrial fibrillation,
indicators within the Quality and             Next steps                                  National Institute for Health and
Outcomes Framework.                           The second phase of nine projects was       Clinical Excellence (NICE) Clinical
                                              launched in October 2009 to spread          Guideline (2006).
Results and achievements                      and embed sustainable improvement
The learning and outcomes from the            applying a developed suite of tools and     2010 National Audit Office ‘Progress in
first phase of projects has been              resources, supported by evidence-based      improving stroke care report’.
identified as one of the six key              learning, and develop alternative
recommended interventions under the           models.                                     Contact details
National Quality and Productivity
agenda within NHS Evidence.                   2010/11 accelerated spread of               Sue Hall
www.library.nhs.uk/qualityandproducitvity     improved detection and optimal              National Improvement Lead
                                              treatment of AF patients to reduce risk     sue.hall@improvement.nhs.uk
In particular we have seen:                   of stroke.
• The early piloting of opportunistic                                                     Dr Campbell Cowan
  screening through pulse palpation at        Supporting information                      Consultant Cardiologist and National
  flu clinics by Bedfordshire and             Full details of the outcomes                Clinical Lead, NHS Improvement - Heart
  Hertfordshire Heart and Stroke              documented and published can be             campbell.cowan@leedsth.nhs.uk
  Network replicated in other areas,          found at: www.improvement.nhs.uk
  eg: Colchester Practice Based                                                           Dr Matt Fay
  Commissioning Group.                        Atrial fibrillation in primary care:        GP and National Clinical Lead
• Opportunistic pulse check prompted          making an impact on stroke prevention       matthew.fay@bradford.nhs.uk
  by flag to GP clinical systems in           (October 2009).
  Durham
• GRASP-AF tool developed and piloted         Commissioning for stroke prevention in
  by West Yorkshire Cardiovascular            primary care: The role of atrial
  Network in collaboration with their         fibrillation (June 2009).
  British Heart Foundation (BHF)
  arrhythmia nurses and PRIMIS+               Heart Improvement: Atrial fibrillation in
  for use on GP clinical systems to           primary care (May 2008).
  identify for review AF patients with
  high risk of stroke, not on warfarin,
  now available for use across England
  for all GP clinical systems via
  www.improvement.nhs.uk/graspaf
• Decision support tool ‘The Auricle’
  www.theauricle.co.uk
Continuing to Improve Cardiac Services   |   11




National roll-out of primary PCI for ST segment
elevation myocardial infarction
Aims of the project                          4. Liaising with Myocardial
The National Infarct Angioplasty Project        Infarction National Audit Project
(NIAP) was published in October 2008.           (MINAP) to monitor national
This demonstrated that a strategy of            progress of the roll-out
primary PCI (angioplasty) for patients          programme.
presenting with ST segment elevation         5. Sharing national learning via the
myocardial infarction was feasible in a         reperfusion web pages and the
UK setting. Following the publication,          primary PCI newsletter.
the Government stated that primary
PCI would be rolled out to cover 95%         Results and achievements
of the population within three years.        Progress has been rapid. In the year
NHS Improvement was invited to               to 1 April 2009, 10,048 ST elevation
facilitate this roll-out process.            MI patients were treated with
                                             thrombolysis and 7,919 were treated
Approach taken                               with primary PCI. Between 1 April 2009
The principal aim of the project was to      and 1 December 2009, there was a
ensure that primary PCI became the           ‘crossing over’ with PPCI becoming the
default treatment for the vast majority      dominant reperfusion strategy. During
of patients in England presenting with       this eight month period, 4,835 patients
ST segment elevation myocardial              received thrombolysis compared with
infarction. This necessitated a 24/7 PPCI    6,643 treated with primary PCI. Thus
service. This in turn meant that not all     58% of those patients receiving
acute hospitals, and not even all PCI        reperfusion treatment received PPCI
centres, would be able to provide this       during the first eight months of the       Next steps
service. For this reason, a cardiac          current MINAP year compared with           1.Interim report
network approach was taken to find a         44% in the previous year. Currently, all   April 2010 represents the half-way
local solution for each network. In          cardiac networks in England have a         point in the three year PPCI roll-out. A
some areas, a solution for a Strategic       strategy to deliver PPCI to their          survey of the cardiac networks is
Health Authority (SHA) which included        population by October 2011. Between        planned together with comparison of
several cardiac networks was sought.         April and November 2009, the               their actual PPCI rates from the MINAP
The role of NHS Improvement in the           commencement of PPCI roll-out              database. These will then be
roll-out of PPCI was that of facilitation.   programmes was captured by the             incorporated into an interim report
This included:                               MINAP data collection which showed         which should highlight if there are any
                                             that 8 cardiac networks were providing     areas of concern nationally.
1. Providing bespoke advice to               PPCI to 30-70% of their ST elevation
   cardiac networks and SHAs on              MI patients by the end of November         2.Patient information
   their PPCI roll-out plans.                2009 having been providing PPCI to         Patients who have a primary PCI have
2. Providing generic guidance on             less than 30% of their population eight    shorter hospital stays and with these
   PPCI roll-out (eg publication of a        months previously.                         short stays come the challenge of
   Guide to Implementing Primary                                                        giving patients and carers the
   Angioplasty (April 2009).                                                            information they require prior to
3. Liaising with DH through the                                                         discharge. Guidelines for staff that care
   Cardiac Emergencies Board on                                                         for these patients are in development.
   issues around PPCI roll-out.
12 | Continuing to Improve Cardiac Services




3. PCI audit                                  Contact details
The Care Quality Commission have
set a standard of 150 minutes                 Carol Marley
door-to-balloon time for PPCI. This is a      National Improvement Lead
‘whole service’ standard since the time       NHS Improvement
interval may include data collection          carol.marley@improvement.nhs.uk
from the ambulance service, from a
non-PPCI hospital and from the PPCI           Dr Jim McLenachan
centre. Data collection for around this       Consultant Cardiologist and National
standard is, therefore, more challenging      Clinical Lead, NHS Improvement - Heart
than for a simple door-to-balloon time        jim.mclenachan@leedsth.nhs.uk
within one institution. Nevertheless, it is
important that we collect whole service       Sheelagh Machin
data. It is equally important that the        Director - NHS Improvement
results of PPCI are set in the context of     sheelagh.machin@improvement.nhs.uk
outcomes of the total ST elevation MI
population to ensure that shocked and
elderly patients, usually those with
most to gain from PPCI, are benefiting
from appropriate access to primary PCI.

Supporting information
Department of Health (2008) Treatment
of Heart Attack National Guidance –
Final Report of the National
Angioplasty Project (NIAP).

NHS Improvement (2009) A Guide to
Implementing Primary Angioplasty.

Primary PCI as the preferred reperfusion
therapy in STEMI: it is a matter of time
C J Terkelsen et al, Heart 2009;95:362-
369.

www.improvement.nhs.uk/
heart/reperfusion
Continuing to Improve Cardiac Services   |   13




Arrhythmia - cardiac devices and
inherited cardiac conditions
Aims of the project                        The national clinical leads worked to         number of implants of each type of
Cardiac devices - Facilitate the           support key stakeholders in forming a         device within the UK, broken down by
improvement of implantation rate and       professional clinical organisation the        both network and PCT. Their work has
equity of access by working with key       Association of Inherited Cardiac              demonstrated a dramatic inequity
stakeholders.                              Conditions. The Association of                between different PCTs and networks in
                                           Inherited Cardiac Conditions (AICC)           device implant rates for all three types
Inherited cardiac conditions (ICC) -       brings together professionals from both       of device. Although the database on
Support the review of ICC service          genetics and cardiology who work              which the survey is based contains
provision and framework for future         together supporting patients and              substantial clinical information about
commissioning and professionally led       families affected by and living with an       the clinical recipients of these devices,
performance management.                    inherited cardiac condition.                  most of the emphasis hitherto has been
                                                                                         on device numbers rather than clinical
Project overview                           Results and achievements                      characteristics of recipients.
Cardiac devices - To support               The cardiac devices national survey
improvement and facilitate local           submissions have been reduced                 Whilst the intention for the coming
performance review, two key elements       allowing the 2009 data to be released         year is not for NHS improvement to
were addressed. The first was working      earlier than usual and a reduction of a       focus on cardiac devices as a national
with key stakeholders to help improve      further six months is expected in 2010        workstream, it is hoped that developing
the currently available device             for the 2009 data. In addition, the           and utilising this valuable information
implantation data, collated and            network specific reports have been            will act as a clinical audit tool, which
published by the devices survey team,      released earlier and funded for every         might be used to help define and
which had evolved from an                  network. The expectation is that the          compare patient populations for the
implantation registry. The data was        focus on earlier review of performance        benefit of clinicians, networks,
readily available as a national data set   will support and encourage networks           commissioners and ultimately patients.
and could be commissioned as a             and providers to address any local
cardiac network specific review but due    access and equity issues.                     Supporting information
to delays in registering implants was                                                    For further information visit the
published a year in arrears. The second    For inherited cardiac conditions, NHS         websites at:
element recognised that improving          Improvement hosted a very well                www.improvement.nhs.uk/
service equity and provision could not     attended launch event for the Heart to        heart/arrhythmias
be achieved with one national solution     Heart, a review of ICC services               www.devicesurvey.com
but required local clinical leadership     produced by the PhG foundation.               www.phgfoundation.org
and review to implement change             Further work between the PhG team
tailored to each provider or network’s     and DH has resulted in the Specialist         Contact details
circumstances.                             Commissioning Groups (SCG) agreeing
                                           to consider inherited cardiac conditions      Elaine Kemp
Inherited cardiac conditions - The         services as a priority in their designation   NHS Improvement Lead
national role was to facilitate and        timetable for 2010/11. This work will be      elaine.kemp@improvement.nhs.uk
advise service providers about the         lead by the Yorkshire and Humber SCG.
mechanism for review and                                                                 Dr Campbell Cowan
improvement. Supporting the launch         The Association for Inherited Cardiac         Consultant Cardiologist and National
and dissemination of the Foundation        Conditions has now completed the              Clinical Lead, NHS Improvement - Heart
for Genomics and Population Health         elections for council membership.             campbell.cowan@leedsth.nhs.uk
(PhG foundation) DH commissioned
report released in June 2008.              Next steps                                    Sheelagh Machin
                                           Cardiac devices - For some years the          Director - NHS Improvement
                                           Network Device Survey Group have              sheelagh.machin@improvement.nhs.uk
                                           provided detailed information on the
14 | Continuing to Improve Cardiac Services




Sustaining cardiac pathways - cardiac surgery
Aims of the project
The attention focused on cardiac
diagnostics and 18 week pathways
as part of the portfolio of work
coordinated by NHS Improvement -
Heart during 2007/08 highlighted a
need to shift attention to cardiac
surgery to develop sustainable
solutions. Eight NHS Trusts supported
by their local cardiac networks were
involved as demonstration sites during
2008/09 testing out new approaches to
care and improvement to frontline
patient services. The focus of work
undertaken by these sites considered to
be constraints within the management
of smooth patient flows included the
following:

• Optimising surgical work up
  through models of pre
  assessment
• Referral management                         • Queen Elizabeth Hospital, University   Results and achievements
• Theatre scheduling                            Hospitals Birmingham NHS               Lessons drawn from the demonstration
• Post operative length of stay and             Foundation Trust and Good Hope         sites suggest that quality improvement
  discharge management.                         Hospital, Heart of England NHS         to elective and non elective cardiac
                                                Foundation Trust, Birmingham           surgery services requires smarter
Project overview                                Sandwell and Solihull Cardiac and      working, the enhancement of staff
The eight NHS Trusts supported by their         Stroke Network                         roles and a shared overview of the
local cardiac networks that participated      • Royal Brompton and Harefield NHS       patient journey and patient experience
as lead demonstration sites in the              Foundation Trust, North West London    across referring providers and the
cardiac surgery project were:                   Cardiac and Stroke Networks            tertiary centre.
                                              • St George’s Healthcare NHS Trust,
• Basildon and Thurrock University              South London Cardiac and Stroke
  Hospitals NHS Foundation Trust,               Networks
  Essex Cardiothoracic Centre, Essex          • University Hospitals Birmingham NHS
  Cardiac and Stroke Network                    Foundation Trust: Queen Elizabeth
• Blackpool, Fylde and Wyre Hospitals           Hospital, Heart of England NHS
  NHS Foundation Trust, Royal Victoria          Foundation Trust, Good Hope
  Hospital, Cardiac and Stroke                  Hospital
  Networks in Lancashire and Cumbria          • University Hospitals Leicester:
• Papworth Hospital NHS Foundation              Glenfield Hospital, East Midlands
  Trust, Anglia Cardiac and Stroke              Cardiac and Stroke Network.
  Network
Continuing to Improve Cardiac Services   |   15




Improvement to the patient pathway - summary of recommendations


  1. Referral management services
  There is often an information gap between referring provider units and the tertiary centre:
  • Manage variation in the referral process from provider units and in-house reducing multiple referral points
    through development of agreed referral criteria to relieve pressure on waiting times for surgery.
  • Develop central systems for optimising referral efficiency by streamlining administrative process and referral
    management linking clinical teams across secondary and tertiary care to triage referrals and advise on
    appropriate tests/investigations.
  • Introduce pooled referrals across consultants as this significantly impacts on waiting times.
  • Use appropriate clinical staff to confirm referrals are complete and discuss work up criteria with referrer.
  • Introduce a single point of contact at the tertiary centre for referrers and patients. The role of the trained
    clinical coordinator is pivotal in tracking individual patients and in ensuring the consultant team is kept
    informed of significant events.



  2. Pre-admission provision
  • Manage variation in pre-assessment services.
  • Adopt investigation guidelines which state agreed timeframes from test to planned date of surgery and only carry out
    investigations which are relevant, indicated and likely to alter management.
  • Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical staff and patients.
  • Maximize opportunities for multidisciplinary team assessment and emphasise use of technology an example would be
    use of video link between hospitals.
  • Maximize pre-assessment opportunities as they help manage patient health and reduce risk.
  • Maximize pre admission diagnostics particularly in referring district general hospitals by establishing agreed pre
    operative protocols.
  • Maximize patient work up prior to admission and agree the schedule for each clinical scenario for example surgery
    for coronaries, mitral valve, aortic valve and combination. This has a beneficial effect on waiting times.
  • Train and support key clinical and managerial staff to deliver some of the work undertaken by junior doctors and
    reconfigure services to develop opportunities for other health care professionals to widen their skills and
    scope of relationship with patients. An example is the patient ‘navigator’ role which benefits patients and families by
    providing information and support following attendance at outpatient and pre assessment clinic.
  • Maximize the scope of extended practice for nursing roles working in pre operative assessment clinics functioning as
    part of the consultant led team to streamline cardiac surgery patient care.
  • Maximize inclusion of different staff groupings for example anaesthetists involved in pre assessment to ensure that all
    patients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improve
    operating theatre efficiency and increase patient satisfaction.
  • Continue to provide information and support.
16 | Continuing to Improve Cardiac Services




  3. Scheduling                                 4. Discharge and post operative care management
  • Move toward day of surgery                  • Manage variation in post operative clinical management practice.
    admission as the standard of                • Manage variation in discharge patterns reducing length of stay.
    care for elective surgery as                • Start discharge planning at pre assessment to identify requirement for
    this can improve the patient                  support and home aids to reduce requirement for delayed discharge.
    experience considerably.                    • Involve a range of health care professionals for example occupational
  • Maximize theatre efficiency                   therapists in discharge planning at pre assessment particularly where
                                                  patients and in particular the elderly may have complex needs.
    by reducing waste in the
                                                • Discharge assessment should form part of the central patient record
    system for example right staff
                                                  available throughout the patient journey to all staff groups.
    in place at the right times
                                                • Move toward nurse led discharge.
    with the right equipment.
  • Optimise theatre capacity by
    reducing slot cancellations
    (clinical/non clinical) and by            Next steps                                  employed in meeting the challenge of
    scheduling procedures that                The portfolio of work for 2010/11 will      18 weeks in elective surgery which
    assist with patient flow                  include a focus on non elective care        inevitably required the focus to extend
                                              incorporating cardiology and cardiac        to systems and processes that support
    through intensive treatment
                                              surgery. For an informal discussion         the whole surgical process, elective or
    unit/high dependency unit
                                              please contact either:                      otherwise.
    (ITU/HDU).
  • Where ever possible pool lists            Garry White                                 Resources developed by the
    to reduce waiting times.                  garry.white@improvement.nhs.uk              demonstration sites are available
  • Procedure complexity scores                                                           through the web links and NHS
    developed to assist with                  Wendy Gray                                  Improvement system at
    scheduling developed as part              wendy.gray@improvement.nhs.uk               www.improvement.nhs.uk
    of the multidisciplinary team.                                                        /heart/sustainability
                                              Rhuari Pike
                                              rhuari.pike@improvement.nhs.uk              Contact details

                                              Networks and organisations will be          Wendy Gray
                                              invited to submit an expression of          National Improvement Lead
                                              interest and further details will be        Wendy.gray@improvement.nhs.uk
                                              announced during April.                     Tel: 07884 003659

                                              Supporting information                      Steve Livesey
                                              A Guide to Commissioning Cardiac            Consultant Cardiac Surgeon and
                                              Surgical Services (February 2010) aims      National Clinical Lead, NHS
                                              to share the lessons drawn from             Improvement - Heart
                                              demonstration sites participating in the    steve.livesey@suht.swest.nhs.uk
                                              Cardiac Surgery National Priority Project
                                              of 2008/09 with the wider NHS.              Gordon Murray
                                              This document identifies a range of         Consultant Cardiologist and
                                              initiatives that have been successfully     National Clinical Lead, NHS
                                                                                          Improvement - Heart
                                                                                          gordon.murray@heartofengland.nhs.uk
Continuing to Improve Cardiac Services             |        17




Heart failure
Piloting, testing and promoting
good quality, systematic, heart               Central Manchester: Number of admissions per million population for
failure services across all areas of          heart failure per four quarter period (lines vs %LES introduced (bars))
delivery
Key messages from the 2008/09
National Priority Heart Failure Projects
                                              Admissions per million population


helped inform the five areas needed to
provide a good heart failure service that




                                                                                                                                             % LES Introduced
are listed in NHS 2010-2015: from
good to great, preventative, people-
centred, productive. (DH Dec 2009).

The five areas can be summarised as:
1. Early, accurate diagnosis in
   primary and secondary care: Brain
   natriuretic peptide (BNP) testing,
   echo, rapid access heart failure
   clinics.
2. Optimising management: Up-
                                                                                                     Period
   titration of medication, cardiac
                                                                                  LES   Training   Pre LES     LES     Non LES
   rehabilitation, patient education and
   self-management, and consideration
   for devices.
3. Integrated care: between primary
   and secondary care to provide a          • Local enhanced service for                                 • Reducing length of inpatient stay
   seamless service, but also to include      patients with left ventricular                               - Essex: Reducing the average length
   social care where needed.                  dysfunction in primary care -                                of stay for primary diagnosis heart
4. Care coordinators: to help navigate        Central Manchester: Reducing                                 failure admissions by more than two
   patients with multiple co-morbidities      admissions (30% reduction) and                               days (reduction in annual bed days of
   through complex care plans.                readmissions (50% reduction)                                 1,250) by improving and integrating
5. End of life care: good symptom             through optimising medication and                            the primary and secondary care
   control and support services should        regular review of heart failure                              pathways and introducing NT-proBNP
   be provided where and when                 patients in GP surgeries.                                    to identify patients and prioritise
   needed by patients, in all settings -    • An integrated model of heart                                 echo.
   community, hospice, and hospital.          failure care - East Riding of
                                              Yorkshire: Using simulation software
The 2008/09 projects that helped              to model potential savings from
inform that document:                         introducing BNP testing to primary
                                              care and testing the model, whilst
Whole pathway projects                        also setting up a fully integrated
• Heart failure self management -             service for identified heart failure
  Bassetlaw: Use of a group education         patients across primary and
  programme to empower patients to            secondary care (still in progress).
  self manage their condition and pilot
  the use of social return on investment
  to gauge its’ impact.
18 | Continuing to Improve Cardiac Services




                                                                                       • Developing symptom control
  Essex: Length of stay (LoS) by monthly discharges - Primary diagnosis                  guidelines for heart failure, up to
  of heart failure                                                                       and including the end of life -
                                                                                         North Lincolnshire and Goole:
                                                                                         Improving knowledge and confidence
                                                                                         in symptom control, for all providers
                                                                                         and whatever the setting.
                                                                                       • Enhancing end of life care for
                                                                                         heart failure patients -
                                                                                         Northampton: Developing
                                                                                         guidelines, protocols and referral
                                                                                         pathways to deliver a model for end
                                                                                         of life care in all settings.
                                                                                       • Improvements in palliative care -
                                                                                         referral and pathway
                                                                                         development - West Surrey:
                                                                                         Providing a 24 hour community
                                                                                         service involving all service providers
                                                                                         working together (still in progress).
                                                                                       • Supportive and palliative care for
                                                                                         heart failure - Sussex: Improving
                                                                                         symptom control out of the acute
                                                                                         setting, by joint working with
• Developing community heart                  • Improving the Acute Heart Failure        palliative and community services.
  failure services - Southwark:                 Pathway - West Hertfordshire:
  Establishing a community heart                Using BNP testing on admission to      Why is end of life care in heart
  failure service for the people of             hospital to speed up accurate          failure so important?
  Southwark and ensure that the                 diagnosis, get the patient onto the    Because the cost, both human and
  service suits the black and ethnic            right care pathway and reduce          financial, is so great when it goes
  minority (BME) and female                     readmissions and length of stay        wrong. The case study (on page 17) is
  population by providing clinics closer        (readmissions reduced by 30%).         of a real heart failure patient and charts
  to home (still in progress).                                                         the 12 admissions and 21 further A&E
• Improvement of heart failure                End of life projects                     attendances in her last year of life.
  diagnosis and management in                 • Promoting access to end of life
  North Staffordshire and Stoke:                care provision within a culturally
  Improving diagnosis and                       diverse community - Brent:
  management of patients with left              Developing a multi-disciplinary
  ventricular systolic dysfunction across       community service, improving quality
  North Staffordshire and Shropshire, in        and accessibility, and preventing
  both primary and secondary care, by           unwanted admissions and A&E
  increasing heart failure specialist           attendances (still in progress).
  nurses, streamlining access to
  diagnostics (echo and BNP) and
  increasing specialist involvement
  (moving to phase 2 in April 2010).
Continuing to Improve Cardiac Services   |   19




        Case History: Nora P.

               There are potential savings of
               £20,000+ if these admissions and
               A&E attendances were avoided

               SEPT     OCT        NOV        DEC    JAN   FEB     MAR      APR       MAY   JUN          JUL      AUG
                07       07         07         07     08    08      08       08        08    08           08       08



                H
                4
               DAYS
                               H
   ADMISSION




                               12         H         H
                              DAYS
                                          9
                                         DAYS
                                                     4       H
                                                    DAYS            H
                                                             9
                                                            DAYS    5
                                                                   DAYS    H
                                                                           9      H   H
                                                                          DAYS
                                                                                  7                H       3
                                                                                                                 H
                    TOTAL of admissions = 84 bed days                                  1
                                                                                 DAYS DAY                 DAYS
                                                                                                   4
                                                                                                  DAYS
                                                                                                               DIED   H
                                                                                                                       17
                                                                                                                      DAYS




Next steps                                                          David Walker
There is potential in all these five areas                          Consultant Cardiologist and National
to improve the quality of heart failure                             Clinical Lead, NHS Improvement - Heart
services and also to improve                                        david.walker@esht.nhs.uk
productivity and our work for 2010-11
and beyond is to both test and spread                               Sheelagh Machin
the ways that these can be done.                                    Director - NHS Improvement
                                                                    sheelagh.machin@improvement.nhs.uk
Contact details
                                                                    www. improvement.nhs.uk/
Candy Jeffries                                                      heart/heartfailure
National Improvement Lead
Tel: 0116 222 1415
candy.jeffries@improvement.nhs.uk

Dr James Beattie
Consultant Cardiologist and National
Clinical Lead, NHS Improvement - Heart
james.beattie@heartofengland.nhs.uk

Mike Connolly
Macmillan Nurse Consultant in
Supportive and Palliative Care and
National Clinical Lead, NHS
Improvement - Heart
michael.connolly@uhsm.nhs.uk
20 | Continuing to Improve Cardiac Services




Cardiac rehabilitation
Aims of the project
The overall aim of this project, which
began in September 2008, continues to
be improved access, equity of provision
and better uptake to quality cardiac
rehabilitation (CR) services for heart
attack, angioplasty and coronary artery
bypass grafts (CABG) patients. The
NICE recommendations on cardiac
rehabilitation (NICE clinical guidelines
CG48 on myocardial infarction (MI):
secondary prevention) and the NICE
commissioning guide on cardiac
rehabilitation were used as a resource
to support improved commissioning.
The projects have worked closely with
providers, commissioners, patients and
carers in planning services; shaping
workforce and multi-disciplinary team
approaches.

Project overview
NHS Improvement cardiac rehabilitation        Two further projects joined the national   two monthly meetings, to devise
projects have included 16 sites across        programme at the end of 2009               solutions and share their learning. Led
12 networks. The project sites are:           11. MyAction Westminster                   by the national improvement lead and
                                              12. North Yorkshire and York PCT.          national clinical lead for cardiac
1. Derbyshire County PCT                                                                 rehabilitation at NHS Improvement and
2. South West and East London                 The emphasis varies within in each         supported by the national clinical
    Cardiac and Stroke Networks               project however most of the projects       advisor these meetings proved a very
3. North Lincolnshire and Goole               involved redesign of services with a       successful method of providing peer
    NHS Trust                                 view to commissioning integrated           support. Learning about wider national
4. Dorset Cardiac and Stroke Network          services across an area, or advising       issues such as work around tariff
5. NHS North of Tyne, North of                commissioners of their next steps in       negotiations, combined with other
    England Cardiovascular Network            service commissioning. All of the          projects proved invaluable to
6. Shropshire and Staffordshire Heart         projects worked on inequities,             progressing individual projects.
    and Stroke Network                        increasing uptake and timely access to
7. Surrey Heart and Stroke Network            services, involvement of patients and      Project teams shared learning via the
8. Black Country Cardiovascular               carers in informing redesign and           NHS Improvement System and on a
    Network                                   improved information.                      website giving both the project teams
9. North West London Cardiac and                                                         and the wider NHS access to material
    Stroke Network – PPCI project             Approach taken                             from the project team days, wider
10. Peninsula Heart and Stroke                Working with cardiac networks,             information relevant to cardiac
    Network.                                  individual PCTs and Trusts, project        rehabilitation, news about tariff and
                                              teams were supported by a series of        links to other areas of interest.
Continuing to Improve Cardiac Services   |   21




Where required one-to-one support at     (Effectiveness), new community and           Next steps
the improvement site was undertaken      home based programme for ischaemic           NHS Improvement is jointly leading the
by the national programme lead and       heart disease (IHD), outcome measures,       development of a CR Commissioning
national clinical lead. This was         clear management plans, effective use        Pack for PCTs with the Strategic
especially useful in specification       of staff and programmes. (Experience)        Development Unit at the Department
development and procurement events.      Increased patient choice, care provided      of Health. NHS Improvement will take
                                         closer to home, improved patient             responsibility and lead a national roll-
The team has also supported tariff       information                                  out of the Commissioning Pack from
development in rehabilitation which      INNOVATION - Rehab-led follow up,            June 2010 which will aim, within the
has helped projects with commissioning   drug therapy reviews, local task group       context of quality and productivity, to
and business case initiatives.           acting to coordinate all quality             increase the numbers of patients
                                         initiatives                                  receiving a quality cardiac rehabilitation
Results and achievements                 PRODUCTIVITY - Increased number of           service.
The main outputs of the projects         patients accessing rehab, reduced hand
have been:                               offs, using and scheduling staff more        Supporting information
                                         effectively, rehab led follow up –           Cardiac Rehabilitation National Priority
• Redesign of service pathways           reduces need for outpatient department       project: Lessons and learning one year
• Production of detailed service         attendance, production of business           on…. (October 2009).
  specifications and business cases      case for CR.
• One project undertaking full                                                        Contact details
  procurement                            A major strength of NHS Improvement
• New and innovative service models      has been the ability to share expertise      Linda Binder
  e.g. heart failure rehabilitation in   and experiences across the different         National Improvement Lead
  community                              workstreams which has clearly led to         linda.binder@improvement.nhs.uk
• Increase in numbers undertaking        greater productivity and quality
  rehabilitation                         outcomes benefiting other aspects of         Professor Patrick Doherty
• Improved equity of access              NHS service delivery. This has placed        National Clinical Lead
• Reduced waiting times for CR           CR in the driving seat for steering          P.Doherty@yorksj.ac.uk
• Clinical pathway development to        national initiatives such as tariff
  ensure uptake of rehabilitation for    implementation and commissioning.            Dr Jane Flint,
  PPCI patients                                                                       National Clinical Advisor
• Economies of scale by integration     “Now is not a time for standing still         Jane.Flint@dgoh.nhs.uk
  with national heart failure, cardiac   rather it is time to invest in NHS
  surgery and PPCI programmes.           Improvement and engage with                  Julie Harries
                                                                                      Director
Many of the outcomes from the
                                         the quality and productivity                 Julie.harries@improvement.nhs.uk
projects meet the quality, innovation    agenda. I believe CR is one of the
and productivity (QIPP) agenda. These    best quality and productivity cases          www.improvement.nhs.uk/
include:                                 around and that the CR priority              heart/cardiacrehabilitation
                                         projects has the appropriate focus
QUALITY - (Safety) Centralised referral  and skills to deliver service
and patient tracking, standardised
protocols and procedures, risk
                                         redesign, innovative commissioning
stratification forms, governance         and improved quality”.
standards, skills competency             Professor Patrick Doherty
assessment, service specifications       National Clinical Lead NHS Improvement
22 | Continuing to Improve Cardiac Services




NHS Improvement System
What is it?                                   Where can I see a
The NHS Improvement System is a               demonstration of the system?
comprehensive, online tool to support         Demonstrations of some of the key
sharing of quality service improvement        modules are available on the
resources in NHS services. Giving you         improvement system home page at:
direct access to useful information and       www.improvement.nhs.uk/
stories from around the country, it will      improvementsystem
assist you in your own service
improvement work.                             Who can use the system?
                                              The system is free of charge and can be
Why use it?                                   used by all staff working for NHS
The NHS Improvement System actively           organisations in England.
helps organisations to effectively
achieve their objectives in line with         How can I register to use the
World Class Commissioning. It enables         system?
users to be more strategic and align          Access to the system is controlled
long-term goals that can help to deliver      by user ID and password.
high quality, patient focussed health
outcomes.                                     To request an ID contact
                                              support@improvement.nhs.uk
Which specialties are included?
The system can be used to support
sustainable service improvement
in any specialty.

What does it contain?
• Service improvement tools
  and resources
• Practical guidance
• Case studies
• Useful contacts
• Signposting and links.
Resources
All the publications listed below           Delivering the NHS Health Check: A          National Priority Projects 2007/08
are available to download at:               Practical Guide to Point of Care            Summary Documents
www.improvement.nhs.uk/                     Testing                                     Summary documents from the Heart
publications                                Identifies some of the pros and cons to     Improvement Programme’s 2007/08
                                            the use of Point of Care Testing (POCT)     national priority projects:
                                            as well as practical ‘solutions’ and        • Making Best Use of Inpatient Beds
A guide to commissioning                    learning from the field (November           • Atrial Fibrillation in Primary Care
cardiac surgical services                   2009).                                      • 18 Weeks Whole Pathways
Eight NHS Trusts supported by their                                                     • 18 Weeks - Focus on Cardiac
local cardiac networks were involved as     Heart Failure - A quick guide to              Diagnostics.
demonstration sites during 2008/09 in       quality commissioning across the
the Cardiac Surgery National Priority       whole pathway of care                       Guidance on Risk Assessment
Project. Lessons drawn from these sites     This practical guide sets out to help       and Stroke Prevention for Atrial
are outlined in the publication 'A Guide    commissioners develop integrated heart      Fibrillation (GRASP-AF) Tool
to Commissioning Cardiac Surgical           failure services by highlighting evidence   This tool should be used as part
Services' (March 2010).                     based practice and measurable               of a systematic approach to the
                                            outcomes. It draws on the NICE              identification, diagnosis and optimal
Cardiac Rehabilitation - National           Commissioning Guidelines (Feb 2008),        management of patients with AF
Priority Projects: Lessons and              Our NHS Our Future (specifically long       to reduce their risk of stroke.
learning one year on...                     term conditions, urgent care and end        www.improvement.nhs.uk/graspaf
Cardiac rehabilitation (CR) is a national   of life). (September 2008).
priority project of NHS Improvement                                                     Using Discovery Interviews
focusing on increasing the access to,       Atrial fibrillation in primary care:        to improve care
equity of provision and uptake of CR        making an impact on stroke                  www.improvement.nhs.uk/
services for heart attack, angioplasty      prevention                                  discoveryinterviews
and CABG patients. The project              This document aims to capture the final
summaries include issues to be              summary of their individual approach,       Improving Cardiac Patient
addressed, baseline position, actions       lessons learned, improvements to            Pathways: The Sustainability
taken, key learning, QIPP outcomes and      practice and quality outcomes, also         Toolkit
results to date from the 11 projects        sharing tools and resources developed       www.improvement.nhs.uk/
participating in this work (October         to enable other health communities to       heart/sustainability
2009).                                      drive this agenda forward (October
                                            2009).                                      The Cardiac Data Dashbord
A Guide to Implementing                                                                 www.improvement.nhs.uk/
Primary Angioplasty                         Commissioning for Stroke                    heart/dashboard
Since the publication of new national       Prevention in Primary Care: the role
good practice guidance on treatment         of Atrial Fibrillation
of heart attack, NHS Improvement has        Developed following a national
looked at the major issues and              consensus meeting of opinion leaders
obstacles to implementing primary           in the field, this document is to develop
percutaneous coronary angioplasty           a concerted strategy towards the
(PPCI) services across England and all      management of AF in primary care, in
the learning has now been pulled            particular anticoagulant management
together in a useful implementation         and its significance in relation to
guide (June 2009).                          reduction in the risk of stroke (June
                                            2009).
CANCER




DIAGNOSTICS




HEART




LUNG




STROKE



              NHS Improvement

              With over ten years practical service improvement experience in cancer,
              diagnostics and heart, NHS Improvement aims to achieve sustainable
              effective pathways and systems, share improvement resources and
              learning, increase impact and ensure value for money to improve the
              efficiency and quality of NHS services.

              Working with clinical networks and NHS organisations across England,
              NHS Improvement helps to transform, deliver and build sustainable
              improvements across the entire pathway of care in cancer, diagnostics,
              heart, lung and stroke services.


              3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
              Telephone: 0116 222 5184 | Fax: 0116 222 5101


              www.improvement.nhs.uk
                                                                                        ©NHS Improvement 2010 | All Rights Reserved | March 2010




              Delivering tomorrow’s
              improvement agenda
              for the NHS

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Continuing to Improve Cardiac Services - National Project Summaries 2009/10

  • 1. NHS CANCER NHS Improvement DIAGNOSTICS Continuing to Improve HEART Cardiac Services Heart Improvement Programme National Project Summaries 2009/10 LUNG STROKE
  • 3. Continuing to Improve Cardiac Services | 3 Contents Foreword 4 “ So far, improvements in the pathway and transfer arrangements have saved Introduction NHS Health Check 5 7 the equivalent of some 959 Atrial fibrillation in primary care 9 NHS beds each year across England. We know that National roll-out of primary PCI for ST there is a lot more that can segment elevation myocardial infarction 11 be done to take this further saving the NHS a great deal Arrhythmia - cardiac devices and inherited cardiac conditions 13 of money and patients a great deal of stress and Sustaining cardiac pathways - ” worry. cardiac surgery 14 Professor Roger Boyle CBE, Heart failure 17 National Director for Heart Disease and Stroke Cardiac rehabilitation 20 Signpost to Improving Cardiac Inter Hospital Transfers, Heart Improvement Programme, NHS Improvement System 22 (2007) Resources 23
  • 4. 4 | Continuing to Improve Cardiac Services Foreword In the 10 years since the launch of the National But there is more to be done - there are still Service Framework (NSF) for Coronary Heart unnecessary waits for transfer to surgical and Disease in 2000, we have seen a substantial specialist centres. The recent National Audit of improvement in cardiac services which has led Cardiac Rehabilitation (NACR) figures show the way in the NHS for improved and equitable that uptake remains low and that access to services. Mortality rates have fallen commissioning and provision of adequate quickly and health inequalities have narrowed. cardiac rehabilitation remains a challenge; the Waiting times for diagnosis, heart surgery and provision of integrated heart failure services angioplasty have fallen dramatically and the across the whole patient pathway is also in Professor Roger Boyle, CBE care of patients with acute coronary syndromes need of focused attention. National Director for Heart has changed dramatically. We are operating Disease and Stroke, on more people with higher levels of risk and As we move forward, we face an even bigger Department of Health co-morbidity, whilst delivering better outcomes. challenge to continue to provide high quality We have also witnessed opportunities for care while at the same time delivering it much health care professionals to widen their skills more efficiently. This will be the biggest and expand their roles and scope of practice. challenge that has faced us in the history of the NHS. The progress and improvements made over the last 10 years to achieve the NSF have been I hope you will join me in celebrating all that made possible by a collaborative effort by all we have achieved together at the NHS organisations and staff across the NHS. The Improvement – Heart Conference which marks CHD Collaborative started in 2000 with just 11 the 10th anniversary of the National Service local sites, moving quickly to 30 collaboratives Framework. The following pages outline for and was followed by the development of the wider NHS the range of national areas of clinical networks. Today, cardiac networks work delivered by NHS Improvement – Heart, continue to be uniquely placed to assist with that have helped increase productivity and the delivery of the quality agenda by linking efficiency in services and have improved the clinicians, managers and commissioners experience for cardiac patients and staff. together in every aspect of the patients’ journey through primary, secondary and tertiary care. They continue to be well positioned to Professor Roger Boyle CBE reflect local relationships between clinicians National Director for Heart Disease across organisational boundaries to further and Stroke, Department of Health develop safe and effective pathways of care for patients by providing an opportunity for clinicians and managers to work together on the redesign and commissioning agenda. The work of NHS Improvement and its predecessor organisations has been a constant source of support to these improvements and pivotal in the development of systems that deliver high quality care.
  • 5. Continuing to Improve Cardiac Services | 5 Introduction This document details the areas that the Moving on to next year, the new priorities Heart Improvement Programme has been have already been agreed. Inevitably, given working on during 2009/10, briefly the financial context in which we are now describing the various ideas that have been working, there is a focus on productivity, but tested by commissioners and providers across that does not mean that quality of care is England. The priority areas were agreed at relegated to second place and we look the start with the policy team with input forward to expressions of interest from from the cardiac networks. The networks anyone who is committed to developing new were then asked to put forward proposals ways of working and improving services for Mark Dancy for work in these areas and selected projects patients. Consultant Cardiologist and National Clinical Chair, were facilitated both by the networks and by NHS Improvement - Heart the national team. We chose projects that Priority projects for 2010/11 had clear objectives and scope, were achievable in a manageable timeframe Cardiac rehabilitation (usually less than two years), and would The work will aim to increase the provision produce new ways of working that could be and uptake of cardiac rehabilitation (CR) by adopted by others. working with the Department of Health to develop a commissioning pack designed to This summary document is not intended to help PCTs and providers improve the describe the individual projects in detail, but specification, commissioning and potential further information is easily available from procurement of CR services. The the contacts given in the text. I would commissioning pack will form the main tool encourage anyone interested in carrying out in a programme of improvement work and similar work to get in touch with the teams its roll out and implementation will be who have been involved in these priority supported by NHS Improvement. projects as they have invested considerable resource learning what works and what Heart failure doesn’t and that can save a lot of time and As highlighted in ‘NHS 2010 - 2015: From anguish. good to great’ (2009,) the main aim of this work will be to improve clinical outcomes As you will see from the descriptions of the and patient experience by decreasing the projects, there have been some very number of emergency admissions, successful initiatives which have measurably readmissions and in-patient bed days improved the quality of care for patients and through optimising care for patients with carers, and I congratulate the teams on their heart failure. The scope will include early hard work and perseverance. If others can accurate diagnosis, optimising management, take these ideas and develop them in their integrated care, the role of the care own localities, the potential health gain is coordinator and end of life care. considerable.
  • 6. 6 | Continuing to Improve Cardiac Services Reducing avoidable delays in non elective inpatient management Cardiac devices This initiative builds on lessons learned in This initiative will continue to engage with elective inpatient management for surgery network and provider device clinical leads to and revascularisation and in previous review local service provision and address interhospital transfer studies. The work aims equity of access in cardiac networks. This will to improve clinical outcomes and patient be underpinned by supporting the device experience by decreasing in-patient bed survey team to drive up data quality and days through optimising care for patients submission timeliness whilst expanding the with acute coronary syndromes (ACS), functionality of existing data sources for arrhythmias and those requiring cardiac clinical users for clinical audit and surgery. commissioning purposes. Atrial fibrillation NHS Health Check This work will build on existing priority Work to support the implementation of this project work on atrial fibrillation (AF) with a major initiative will move from NHS view to accelerating progress, sharing Improvement to NHS Diabetes and Kidney lessons learned and extending and Care from May 2010. NHS Health Check embedding the use of tools, methodologies remains a key policy initiative for the and resources for AF developed and tested prevention of cardiovascular disease and during the pilot and prototype phases. The work in cardiac and stroke networks on this focus will be on raising awareness of AF, important area will continue. training and education of clinicians in detection and treatment, exploring all Some of the projects from this year are still opportunities for screening for AF and running, but networks will be looking out for ensuring anticoagulation and treatment are people who think they may be able to optimised in both primary and secondary contribute their ideas in the various project care. A substantial reduction in the number areas for 2010/11 and if you think you might of resulting strokes is anticipated and the want to join us I would encourage you to work will contribute considerably to the speak to your network as soon as possible quality and productivity challenge. even if only to discuss your proposal informally. Primary angioplasty (reperfusion) This work will involve a continuation of the primary percutaneous coronary Mark Dancy intervention (PPCI) project workstream with National Clinical Chair implementation across England and the NHS Improvement - Heart development of a sustainable service across the whole patient journey. This will include a focus on the adoption of robust cardiac rehabilitation pathways and an emphasis on the improvement of the data quality for local and national audit.
  • 7. Continuing to Improve Cardiac Services | 7 NHS Health Check Aims of the project To support the successful implementation and delivery of the NHS Health Check programme - a systematic and integrated programme of vascular risk assessment and management which will offer preventative checks to all eligible people aged 40-74 to assess their risk of vascular disease (heart disease, stroke, diabetes and kidney disease) followed by appropriate management and interventions. The proposals for the NHS Health Check programme (formerly vascular checks) were set out in ‘Putting Prevention First’, published on 1 April 2008 and aim to ensure greater focus on the prevention of vascular disease and a reduction in health inequalities. Implementation of this major national programme began in April 2009 and all Primary Care Approach taken the Department of Health, and to Trusts are expected to achieve full roll The NHS Health Check Learning signpost to other useful information out by 2012/13. Network includes NHS commissioners sources. and providers, independent and Project overview voluntary sector organisations, The NHS Health Check Learning To coincide with the publication of individuals and a wide range of other Network website acts as a central Putting Prevention First, NHS stakeholders who are interested or repository for the network and has Improvement, in collaboration with the involved in the implementation of the been developed to help commissioners Department of Health, established a NHS Health Check, including the and providers locate relevant resources national Learning Network in order to cardiac and stroke networks. and information to support local learn from, build upon and share the implementation. It includes details of learning and experience of both The Learning Network is underpinned national workshops as well as key existing and emerging vascular risk by a series of interactive workshops guidance documents and latest news assessment and management with a strong focus on sharing and relating to the NHS Health Check programmes across the country. The learning and featuring presentations, programme, a useful links section, an Learning Network has focused on discussions and interactive group work expanding number of case studies, and tackling the many challenges to around the emerging issues and a resource library containing implementation and delivery of the themes. ‘documents for sharing’- to save programme, including commissioning commissioners and providers from and procurement, workforce capacity, The Learning Network is also supported reinventing the wheel. training and education, informatics, by the publication of a regular eBulletin checks in community settings, which aims to keep subscribers up to leadership and clinical engagement date with news and information from and so on. across the Learning Network and from
  • 8. 8 | Continuing to Improve Cardiac Services NHS Improvement has also supported Current estimates indicate that over Contact details 19 carefully selected ‘test bed’ sites to 85% of PCTs in England will have investigate different aspects and commenced roll out of NHS Health Julie Harries models of delivery to help inform policy Check in 2009/10 and it is likely that Director and assist with the development of the establishment of the national julie.harries@improvement.nhs.uk further guidance. Funded by the Learning Network has made a Department of Health, learning from significant contribution to this in Mel Varvel the test bed programme is currently addition to tangible (figures to be National Improvement Lead being shared across the Learning confirmed) progress towards the mel.varvel@improvement.nhs.uk Network, largely via the production of a delivery of 1,000,000 checks by April series of practical implementation 2010 (as cited in Working Together – guides, the first of which was published Public Services On Your Side published in November 2009. in March 2009). Results and achievements Next steps To date, NHS Improvement, alongside The national Learning Network is set the Department of Health, has to continue to support ongoing facilitated seven national learning implementation and delivery though events attended by well over 1,000 the facilitative role played by NHS delegates. These national workshops Improvement will transfer to NHS have generated a great deal of interest Diabetes and Kidney Care in Spring from a wide range of stakeholders 2010. across the country and have been very well received and evaluated by Supporting information attendees: To find out more about the NHS Health Check Learning Network, and to “ Today's workshops have been download any of the supporting guidance and resources, visit the fantastic. It's really valuable to website at: www.improvement.nhs.uk/ hear what's happening from nhshealthcheck the centre and in other areas.” Further information on the national Eight eBulletins have been published to policy can be found on the a growing distribution list of almost Department of Health’s website at: 900 people, and the website continues www.dh.gov.uk/nhshealthcheck to achieve a high ‘hit rate’. Public-facing information is available on The first implementation guide on Point the NHS Choices website at: of Care Testing proved extremely www.nhs.uk/Planners/NHSHealthCheck popular and has received very positive /Pages/NHSHealthCheck.aspx feedback.
  • 9. Continuing to Improve Cardiac Services | 9 Stroke prevention in primary care: managing atrial fibrillation Aims of the project Key areas for piloting new To improve quality outcomes for approaches centred on: patients with atrial fibrillation (AF) and • Detection of AF through opportunistic reduction in health and social care costs screening at flu clinics by reducing their risk of stroke through • Local enhanced service (LES) schemes service improvement to improve for detection, screening and review detection, diagnosis and optimal of AF therapy and management in primary • New models for anti-coagulation care. services in primary and community settings Chapter Eight of the National Service • Development of tools to support the Framework for Coronary Heart Disease; review of patients with AF, risk Arrhythmias and Sudden Cardiac stratify for stroke and consider Death, published in March 2005, set optimal therapy out the quality requirements for the • Guidelines for primary to secondary prevention and treatment of patients care referral. with cardiac arrhythmias. In December 2008, the publication of the National All projects found the need to include Stroke Strategy affirmed the education for professionals and importance of this work for stroke patients around: prevention within Quality Marker 2 This treatment is also highly cost • Pulse palpation ‘Managing Risk’. effective. The treatment of AF with • Barriers to anti-coagulation in warfarin reduces risk of stroke by primary care Atrial fibrillation is the most common 50-70%: • ECG training and interpretation sustained dysrhythmia, affecting at • The estimated total cost of • Patient awareness. least 600,000 (1.2%) people in England maintaining one patient on warfarin alone. It is also a major predisposing for one year, including monitoring, is Approach taken factor to stroke, with 16,000 strokes £383 These projects led by NHS Improvement annually in patients with AF of which • The cost per stroke due to AF is Heart and Stroke Programmes, sought approximately 12,500 are thought to estimated to be £11,900 in the first to work with primary care trusts (PCTs), be directly attributable to AF. year after stroke occurrence. general practices, practice based consortia (PBC) acute trusts and The annual risk of stroke is five to six Project overview voluntary organisations to address the times greater in AF patients than in The first phase of priority projects were detection of atrial fibrillation, whether people with normal heart rhythm and is established in October 2007 and patients were appropriately treated therefore a major risk factor for stroke. completed April 2009. Eighteen with anti-coagulants and to consider Uniquely, it also in an eminently individual projects were established the best pathways for managing atrial preventable cause of stroke with a across 15 cardiac and stroke networks fibrillation in primary care. simple highly effective treatment. A variety of approaches were undertaken responding to the needs of Regular peer support meetings were the local health communities. held to encourage the sharing of resources, learning and collaborative working to drive forward improvements in care and maximise benefits.
  • 10. 10 | Continuing to Improve Cardiac Services In parallel, at a national level, NHS Based on numbers needed to treat National Publications Improvement has sought to achieve a ranging from 25 to 37 (Kerr), the costs National Stroke Strategy – Quality consensus approach across England to of each stroke prevented with warfarin Marker 2: Managing Risk (2007). the management of AF patients within are in the range £9,500 to £14,000. primary care with key stakeholders National Service Framework for resulting in the publication of a Each year appropriate anti-coagulation Coronary Heart Disease (CHD) – commissioning guide in May 2009 and could prevent 4,500 strokes in patients Chapter 8: Arrhythmias and Sudden continues to make formal with AF at an additional cost of £63.5 Cardiac Death (2006). representation to influence million. amendments to the current AF Management of atrial fibrillation, indicators within the Quality and Next steps National Institute for Health and Outcomes Framework. The second phase of nine projects was Clinical Excellence (NICE) Clinical launched in October 2009 to spread Guideline (2006). Results and achievements and embed sustainable improvement The learning and outcomes from the applying a developed suite of tools and 2010 National Audit Office ‘Progress in first phase of projects has been resources, supported by evidence-based improving stroke care report’. identified as one of the six key learning, and develop alternative recommended interventions under the models. Contact details National Quality and Productivity agenda within NHS Evidence. 2010/11 accelerated spread of Sue Hall www.library.nhs.uk/qualityandproducitvity improved detection and optimal National Improvement Lead treatment of AF patients to reduce risk sue.hall@improvement.nhs.uk In particular we have seen: of stroke. • The early piloting of opportunistic Dr Campbell Cowan screening through pulse palpation at Supporting information Consultant Cardiologist and National flu clinics by Bedfordshire and Full details of the outcomes Clinical Lead, NHS Improvement - Heart Hertfordshire Heart and Stroke documented and published can be campbell.cowan@leedsth.nhs.uk Network replicated in other areas, found at: www.improvement.nhs.uk eg: Colchester Practice Based Dr Matt Fay Commissioning Group. Atrial fibrillation in primary care: GP and National Clinical Lead • Opportunistic pulse check prompted making an impact on stroke prevention matthew.fay@bradford.nhs.uk by flag to GP clinical systems in (October 2009). Durham • GRASP-AF tool developed and piloted Commissioning for stroke prevention in by West Yorkshire Cardiovascular primary care: The role of atrial Network in collaboration with their fibrillation (June 2009). British Heart Foundation (BHF) arrhythmia nurses and PRIMIS+ Heart Improvement: Atrial fibrillation in for use on GP clinical systems to primary care (May 2008). identify for review AF patients with high risk of stroke, not on warfarin, now available for use across England for all GP clinical systems via www.improvement.nhs.uk/graspaf • Decision support tool ‘The Auricle’ www.theauricle.co.uk
  • 11. Continuing to Improve Cardiac Services | 11 National roll-out of primary PCI for ST segment elevation myocardial infarction Aims of the project 4. Liaising with Myocardial The National Infarct Angioplasty Project Infarction National Audit Project (NIAP) was published in October 2008. (MINAP) to monitor national This demonstrated that a strategy of progress of the roll-out primary PCI (angioplasty) for patients programme. presenting with ST segment elevation 5. Sharing national learning via the myocardial infarction was feasible in a reperfusion web pages and the UK setting. Following the publication, primary PCI newsletter. the Government stated that primary PCI would be rolled out to cover 95% Results and achievements of the population within three years. Progress has been rapid. In the year NHS Improvement was invited to to 1 April 2009, 10,048 ST elevation facilitate this roll-out process. MI patients were treated with thrombolysis and 7,919 were treated Approach taken with primary PCI. Between 1 April 2009 The principal aim of the project was to and 1 December 2009, there was a ensure that primary PCI became the ‘crossing over’ with PPCI becoming the default treatment for the vast majority dominant reperfusion strategy. During of patients in England presenting with this eight month period, 4,835 patients ST segment elevation myocardial received thrombolysis compared with infarction. This necessitated a 24/7 PPCI 6,643 treated with primary PCI. Thus service. This in turn meant that not all 58% of those patients receiving acute hospitals, and not even all PCI reperfusion treatment received PPCI centres, would be able to provide this during the first eight months of the Next steps service. For this reason, a cardiac current MINAP year compared with 1.Interim report network approach was taken to find a 44% in the previous year. Currently, all April 2010 represents the half-way local solution for each network. In cardiac networks in England have a point in the three year PPCI roll-out. A some areas, a solution for a Strategic strategy to deliver PPCI to their survey of the cardiac networks is Health Authority (SHA) which included population by October 2011. Between planned together with comparison of several cardiac networks was sought. April and November 2009, the their actual PPCI rates from the MINAP The role of NHS Improvement in the commencement of PPCI roll-out database. These will then be roll-out of PPCI was that of facilitation. programmes was captured by the incorporated into an interim report This included: MINAP data collection which showed which should highlight if there are any that 8 cardiac networks were providing areas of concern nationally. 1. Providing bespoke advice to PPCI to 30-70% of their ST elevation cardiac networks and SHAs on MI patients by the end of November 2.Patient information their PPCI roll-out plans. 2009 having been providing PPCI to Patients who have a primary PCI have 2. Providing generic guidance on less than 30% of their population eight shorter hospital stays and with these PPCI roll-out (eg publication of a months previously. short stays come the challenge of Guide to Implementing Primary giving patients and carers the Angioplasty (April 2009). information they require prior to 3. Liaising with DH through the discharge. Guidelines for staff that care Cardiac Emergencies Board on for these patients are in development. issues around PPCI roll-out.
  • 12. 12 | Continuing to Improve Cardiac Services 3. PCI audit Contact details The Care Quality Commission have set a standard of 150 minutes Carol Marley door-to-balloon time for PPCI. This is a National Improvement Lead ‘whole service’ standard since the time NHS Improvement interval may include data collection carol.marley@improvement.nhs.uk from the ambulance service, from a non-PPCI hospital and from the PPCI Dr Jim McLenachan centre. Data collection for around this Consultant Cardiologist and National standard is, therefore, more challenging Clinical Lead, NHS Improvement - Heart than for a simple door-to-balloon time jim.mclenachan@leedsth.nhs.uk within one institution. Nevertheless, it is important that we collect whole service Sheelagh Machin data. It is equally important that the Director - NHS Improvement results of PPCI are set in the context of sheelagh.machin@improvement.nhs.uk outcomes of the total ST elevation MI population to ensure that shocked and elderly patients, usually those with most to gain from PPCI, are benefiting from appropriate access to primary PCI. Supporting information Department of Health (2008) Treatment of Heart Attack National Guidance – Final Report of the National Angioplasty Project (NIAP). NHS Improvement (2009) A Guide to Implementing Primary Angioplasty. Primary PCI as the preferred reperfusion therapy in STEMI: it is a matter of time C J Terkelsen et al, Heart 2009;95:362- 369. www.improvement.nhs.uk/ heart/reperfusion
  • 13. Continuing to Improve Cardiac Services | 13 Arrhythmia - cardiac devices and inherited cardiac conditions Aims of the project The national clinical leads worked to number of implants of each type of Cardiac devices - Facilitate the support key stakeholders in forming a device within the UK, broken down by improvement of implantation rate and professional clinical organisation the both network and PCT. Their work has equity of access by working with key Association of Inherited Cardiac demonstrated a dramatic inequity stakeholders. Conditions. The Association of between different PCTs and networks in Inherited Cardiac Conditions (AICC) device implant rates for all three types Inherited cardiac conditions (ICC) - brings together professionals from both of device. Although the database on Support the review of ICC service genetics and cardiology who work which the survey is based contains provision and framework for future together supporting patients and substantial clinical information about commissioning and professionally led families affected by and living with an the clinical recipients of these devices, performance management. inherited cardiac condition. most of the emphasis hitherto has been on device numbers rather than clinical Project overview Results and achievements characteristics of recipients. Cardiac devices - To support The cardiac devices national survey improvement and facilitate local submissions have been reduced Whilst the intention for the coming performance review, two key elements allowing the 2009 data to be released year is not for NHS improvement to were addressed. The first was working earlier than usual and a reduction of a focus on cardiac devices as a national with key stakeholders to help improve further six months is expected in 2010 workstream, it is hoped that developing the currently available device for the 2009 data. In addition, the and utilising this valuable information implantation data, collated and network specific reports have been will act as a clinical audit tool, which published by the devices survey team, released earlier and funded for every might be used to help define and which had evolved from an network. The expectation is that the compare patient populations for the implantation registry. The data was focus on earlier review of performance benefit of clinicians, networks, readily available as a national data set will support and encourage networks commissioners and ultimately patients. and could be commissioned as a and providers to address any local cardiac network specific review but due access and equity issues. Supporting information to delays in registering implants was For further information visit the published a year in arrears. The second For inherited cardiac conditions, NHS websites at: element recognised that improving Improvement hosted a very well www.improvement.nhs.uk/ service equity and provision could not attended launch event for the Heart to heart/arrhythmias be achieved with one national solution Heart, a review of ICC services www.devicesurvey.com but required local clinical leadership produced by the PhG foundation. www.phgfoundation.org and review to implement change Further work between the PhG team tailored to each provider or network’s and DH has resulted in the Specialist Contact details circumstances. Commissioning Groups (SCG) agreeing to consider inherited cardiac conditions Elaine Kemp Inherited cardiac conditions - The services as a priority in their designation NHS Improvement Lead national role was to facilitate and timetable for 2010/11. This work will be elaine.kemp@improvement.nhs.uk advise service providers about the lead by the Yorkshire and Humber SCG. mechanism for review and Dr Campbell Cowan improvement. Supporting the launch The Association for Inherited Cardiac Consultant Cardiologist and National and dissemination of the Foundation Conditions has now completed the Clinical Lead, NHS Improvement - Heart for Genomics and Population Health elections for council membership. campbell.cowan@leedsth.nhs.uk (PhG foundation) DH commissioned report released in June 2008. Next steps Sheelagh Machin Cardiac devices - For some years the Director - NHS Improvement Network Device Survey Group have sheelagh.machin@improvement.nhs.uk provided detailed information on the
  • 14. 14 | Continuing to Improve Cardiac Services Sustaining cardiac pathways - cardiac surgery Aims of the project The attention focused on cardiac diagnostics and 18 week pathways as part of the portfolio of work coordinated by NHS Improvement - Heart during 2007/08 highlighted a need to shift attention to cardiac surgery to develop sustainable solutions. Eight NHS Trusts supported by their local cardiac networks were involved as demonstration sites during 2008/09 testing out new approaches to care and improvement to frontline patient services. The focus of work undertaken by these sites considered to be constraints within the management of smooth patient flows included the following: • Optimising surgical work up through models of pre assessment • Referral management • Queen Elizabeth Hospital, University Results and achievements • Theatre scheduling Hospitals Birmingham NHS Lessons drawn from the demonstration • Post operative length of stay and Foundation Trust and Good Hope sites suggest that quality improvement discharge management. Hospital, Heart of England NHS to elective and non elective cardiac Foundation Trust, Birmingham surgery services requires smarter Project overview Sandwell and Solihull Cardiac and working, the enhancement of staff The eight NHS Trusts supported by their Stroke Network roles and a shared overview of the local cardiac networks that participated • Royal Brompton and Harefield NHS patient journey and patient experience as lead demonstration sites in the Foundation Trust, North West London across referring providers and the cardiac surgery project were: Cardiac and Stroke Networks tertiary centre. • St George’s Healthcare NHS Trust, • Basildon and Thurrock University South London Cardiac and Stroke Hospitals NHS Foundation Trust, Networks Essex Cardiothoracic Centre, Essex • University Hospitals Birmingham NHS Cardiac and Stroke Network Foundation Trust: Queen Elizabeth • Blackpool, Fylde and Wyre Hospitals Hospital, Heart of England NHS NHS Foundation Trust, Royal Victoria Foundation Trust, Good Hope Hospital, Cardiac and Stroke Hospital Networks in Lancashire and Cumbria • University Hospitals Leicester: • Papworth Hospital NHS Foundation Glenfield Hospital, East Midlands Trust, Anglia Cardiac and Stroke Cardiac and Stroke Network. Network
  • 15. Continuing to Improve Cardiac Services | 15 Improvement to the patient pathway - summary of recommendations 1. Referral management services There is often an information gap between referring provider units and the tertiary centre: • Manage variation in the referral process from provider units and in-house reducing multiple referral points through development of agreed referral criteria to relieve pressure on waiting times for surgery. • Develop central systems for optimising referral efficiency by streamlining administrative process and referral management linking clinical teams across secondary and tertiary care to triage referrals and advise on appropriate tests/investigations. • Introduce pooled referrals across consultants as this significantly impacts on waiting times. • Use appropriate clinical staff to confirm referrals are complete and discuss work up criteria with referrer. • Introduce a single point of contact at the tertiary centre for referrers and patients. The role of the trained clinical coordinator is pivotal in tracking individual patients and in ensuring the consultant team is kept informed of significant events. 2. Pre-admission provision • Manage variation in pre-assessment services. • Adopt investigation guidelines which state agreed timeframes from test to planned date of surgery and only carry out investigations which are relevant, indicated and likely to alter management. • Introduce ‘one-stops’ for outpatients to avoid wasted clinics for medical staff and patients. • Maximize opportunities for multidisciplinary team assessment and emphasise use of technology an example would be use of video link between hospitals. • Maximize pre-assessment opportunities as they help manage patient health and reduce risk. • Maximize pre admission diagnostics particularly in referring district general hospitals by establishing agreed pre operative protocols. • Maximize patient work up prior to admission and agree the schedule for each clinical scenario for example surgery for coronaries, mitral valve, aortic valve and combination. This has a beneficial effect on waiting times. • Train and support key clinical and managerial staff to deliver some of the work undertaken by junior doctors and reconfigure services to develop opportunities for other health care professionals to widen their skills and scope of relationship with patients. An example is the patient ‘navigator’ role which benefits patients and families by providing information and support following attendance at outpatient and pre assessment clinic. • Maximize the scope of extended practice for nursing roles working in pre operative assessment clinics functioning as part of the consultant led team to streamline cardiac surgery patient care. • Maximize inclusion of different staff groupings for example anaesthetists involved in pre assessment to ensure that all patients presenting for surgery will be adequately assessed as this can reduce cancellation rates, improve operating theatre efficiency and increase patient satisfaction. • Continue to provide information and support.
  • 16. 16 | Continuing to Improve Cardiac Services 3. Scheduling 4. Discharge and post operative care management • Move toward day of surgery • Manage variation in post operative clinical management practice. admission as the standard of • Manage variation in discharge patterns reducing length of stay. care for elective surgery as • Start discharge planning at pre assessment to identify requirement for this can improve the patient support and home aids to reduce requirement for delayed discharge. experience considerably. • Involve a range of health care professionals for example occupational • Maximize theatre efficiency therapists in discharge planning at pre assessment particularly where patients and in particular the elderly may have complex needs. by reducing waste in the • Discharge assessment should form part of the central patient record system for example right staff available throughout the patient journey to all staff groups. in place at the right times • Move toward nurse led discharge. with the right equipment. • Optimise theatre capacity by reducing slot cancellations (clinical/non clinical) and by Next steps employed in meeting the challenge of scheduling procedures that The portfolio of work for 2010/11 will 18 weeks in elective surgery which assist with patient flow include a focus on non elective care inevitably required the focus to extend incorporating cardiology and cardiac to systems and processes that support through intensive treatment surgery. For an informal discussion the whole surgical process, elective or unit/high dependency unit please contact either: otherwise. (ITU/HDU). • Where ever possible pool lists Garry White Resources developed by the to reduce waiting times. garry.white@improvement.nhs.uk demonstration sites are available • Procedure complexity scores through the web links and NHS developed to assist with Wendy Gray Improvement system at scheduling developed as part wendy.gray@improvement.nhs.uk www.improvement.nhs.uk of the multidisciplinary team. /heart/sustainability Rhuari Pike rhuari.pike@improvement.nhs.uk Contact details Networks and organisations will be Wendy Gray invited to submit an expression of National Improvement Lead interest and further details will be Wendy.gray@improvement.nhs.uk announced during April. Tel: 07884 003659 Supporting information Steve Livesey A Guide to Commissioning Cardiac Consultant Cardiac Surgeon and Surgical Services (February 2010) aims National Clinical Lead, NHS to share the lessons drawn from Improvement - Heart demonstration sites participating in the steve.livesey@suht.swest.nhs.uk Cardiac Surgery National Priority Project of 2008/09 with the wider NHS. Gordon Murray This document identifies a range of Consultant Cardiologist and initiatives that have been successfully National Clinical Lead, NHS Improvement - Heart gordon.murray@heartofengland.nhs.uk
  • 17. Continuing to Improve Cardiac Services | 17 Heart failure Piloting, testing and promoting good quality, systematic, heart Central Manchester: Number of admissions per million population for failure services across all areas of heart failure per four quarter period (lines vs %LES introduced (bars)) delivery Key messages from the 2008/09 National Priority Heart Failure Projects Admissions per million population helped inform the five areas needed to provide a good heart failure service that % LES Introduced are listed in NHS 2010-2015: from good to great, preventative, people- centred, productive. (DH Dec 2009). The five areas can be summarised as: 1. Early, accurate diagnosis in primary and secondary care: Brain natriuretic peptide (BNP) testing, echo, rapid access heart failure clinics. 2. Optimising management: Up- Period titration of medication, cardiac LES Training Pre LES LES Non LES rehabilitation, patient education and self-management, and consideration for devices. 3. Integrated care: between primary and secondary care to provide a • Local enhanced service for • Reducing length of inpatient stay seamless service, but also to include patients with left ventricular - Essex: Reducing the average length social care where needed. dysfunction in primary care - of stay for primary diagnosis heart 4. Care coordinators: to help navigate Central Manchester: Reducing failure admissions by more than two patients with multiple co-morbidities admissions (30% reduction) and days (reduction in annual bed days of through complex care plans. readmissions (50% reduction) 1,250) by improving and integrating 5. End of life care: good symptom through optimising medication and the primary and secondary care control and support services should regular review of heart failure pathways and introducing NT-proBNP be provided where and when patients in GP surgeries. to identify patients and prioritise needed by patients, in all settings - • An integrated model of heart echo. community, hospice, and hospital. failure care - East Riding of Yorkshire: Using simulation software The 2008/09 projects that helped to model potential savings from inform that document: introducing BNP testing to primary care and testing the model, whilst Whole pathway projects also setting up a fully integrated • Heart failure self management - service for identified heart failure Bassetlaw: Use of a group education patients across primary and programme to empower patients to secondary care (still in progress). self manage their condition and pilot the use of social return on investment to gauge its’ impact.
  • 18. 18 | Continuing to Improve Cardiac Services • Developing symptom control Essex: Length of stay (LoS) by monthly discharges - Primary diagnosis guidelines for heart failure, up to of heart failure and including the end of life - North Lincolnshire and Goole: Improving knowledge and confidence in symptom control, for all providers and whatever the setting. • Enhancing end of life care for heart failure patients - Northampton: Developing guidelines, protocols and referral pathways to deliver a model for end of life care in all settings. • Improvements in palliative care - referral and pathway development - West Surrey: Providing a 24 hour community service involving all service providers working together (still in progress). • Supportive and palliative care for heart failure - Sussex: Improving symptom control out of the acute setting, by joint working with • Developing community heart • Improving the Acute Heart Failure palliative and community services. failure services - Southwark: Pathway - West Hertfordshire: Establishing a community heart Using BNP testing on admission to Why is end of life care in heart failure service for the people of hospital to speed up accurate failure so important? Southwark and ensure that the diagnosis, get the patient onto the Because the cost, both human and service suits the black and ethnic right care pathway and reduce financial, is so great when it goes minority (BME) and female readmissions and length of stay wrong. The case study (on page 17) is population by providing clinics closer (readmissions reduced by 30%). of a real heart failure patient and charts to home (still in progress). the 12 admissions and 21 further A&E • Improvement of heart failure End of life projects attendances in her last year of life. diagnosis and management in • Promoting access to end of life North Staffordshire and Stoke: care provision within a culturally Improving diagnosis and diverse community - Brent: management of patients with left Developing a multi-disciplinary ventricular systolic dysfunction across community service, improving quality North Staffordshire and Shropshire, in and accessibility, and preventing both primary and secondary care, by unwanted admissions and A&E increasing heart failure specialist attendances (still in progress). nurses, streamlining access to diagnostics (echo and BNP) and increasing specialist involvement (moving to phase 2 in April 2010).
  • 19. Continuing to Improve Cardiac Services | 19 Case History: Nora P. There are potential savings of £20,000+ if these admissions and A&E attendances were avoided SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG 07 07 07 07 08 08 08 08 08 08 08 08 H 4 DAYS H ADMISSION 12 H H DAYS 9 DAYS 4 H DAYS H 9 DAYS 5 DAYS H 9 H H DAYS 7 H 3 H TOTAL of admissions = 84 bed days 1 DAYS DAY DAYS 4 DAYS DIED H 17 DAYS Next steps David Walker There is potential in all these five areas Consultant Cardiologist and National to improve the quality of heart failure Clinical Lead, NHS Improvement - Heart services and also to improve david.walker@esht.nhs.uk productivity and our work for 2010-11 and beyond is to both test and spread Sheelagh Machin the ways that these can be done. Director - NHS Improvement sheelagh.machin@improvement.nhs.uk Contact details www. improvement.nhs.uk/ Candy Jeffries heart/heartfailure National Improvement Lead Tel: 0116 222 1415 candy.jeffries@improvement.nhs.uk Dr James Beattie Consultant Cardiologist and National Clinical Lead, NHS Improvement - Heart james.beattie@heartofengland.nhs.uk Mike Connolly Macmillan Nurse Consultant in Supportive and Palliative Care and National Clinical Lead, NHS Improvement - Heart michael.connolly@uhsm.nhs.uk
  • 20. 20 | Continuing to Improve Cardiac Services Cardiac rehabilitation Aims of the project The overall aim of this project, which began in September 2008, continues to be improved access, equity of provision and better uptake to quality cardiac rehabilitation (CR) services for heart attack, angioplasty and coronary artery bypass grafts (CABG) patients. The NICE recommendations on cardiac rehabilitation (NICE clinical guidelines CG48 on myocardial infarction (MI): secondary prevention) and the NICE commissioning guide on cardiac rehabilitation were used as a resource to support improved commissioning. The projects have worked closely with providers, commissioners, patients and carers in planning services; shaping workforce and multi-disciplinary team approaches. Project overview NHS Improvement cardiac rehabilitation Two further projects joined the national two monthly meetings, to devise projects have included 16 sites across programme at the end of 2009 solutions and share their learning. Led 12 networks. The project sites are: 11. MyAction Westminster by the national improvement lead and 12. North Yorkshire and York PCT. national clinical lead for cardiac 1. Derbyshire County PCT rehabilitation at NHS Improvement and 2. South West and East London The emphasis varies within in each supported by the national clinical Cardiac and Stroke Networks project however most of the projects advisor these meetings proved a very 3. North Lincolnshire and Goole involved redesign of services with a successful method of providing peer NHS Trust view to commissioning integrated support. Learning about wider national 4. Dorset Cardiac and Stroke Network services across an area, or advising issues such as work around tariff 5. NHS North of Tyne, North of commissioners of their next steps in negotiations, combined with other England Cardiovascular Network service commissioning. All of the projects proved invaluable to 6. Shropshire and Staffordshire Heart projects worked on inequities, progressing individual projects. and Stroke Network increasing uptake and timely access to 7. Surrey Heart and Stroke Network services, involvement of patients and Project teams shared learning via the 8. Black Country Cardiovascular carers in informing redesign and NHS Improvement System and on a Network improved information. website giving both the project teams 9. North West London Cardiac and and the wider NHS access to material Stroke Network – PPCI project Approach taken from the project team days, wider 10. Peninsula Heart and Stroke Working with cardiac networks, information relevant to cardiac Network. individual PCTs and Trusts, project rehabilitation, news about tariff and teams were supported by a series of links to other areas of interest.
  • 21. Continuing to Improve Cardiac Services | 21 Where required one-to-one support at (Effectiveness), new community and Next steps the improvement site was undertaken home based programme for ischaemic NHS Improvement is jointly leading the by the national programme lead and heart disease (IHD), outcome measures, development of a CR Commissioning national clinical lead. This was clear management plans, effective use Pack for PCTs with the Strategic especially useful in specification of staff and programmes. (Experience) Development Unit at the Department development and procurement events. Increased patient choice, care provided of Health. NHS Improvement will take closer to home, improved patient responsibility and lead a national roll- The team has also supported tariff information out of the Commissioning Pack from development in rehabilitation which INNOVATION - Rehab-led follow up, June 2010 which will aim, within the has helped projects with commissioning drug therapy reviews, local task group context of quality and productivity, to and business case initiatives. acting to coordinate all quality increase the numbers of patients initiatives receiving a quality cardiac rehabilitation Results and achievements PRODUCTIVITY - Increased number of service. The main outputs of the projects patients accessing rehab, reduced hand have been: offs, using and scheduling staff more Supporting information effectively, rehab led follow up – Cardiac Rehabilitation National Priority • Redesign of service pathways reduces need for outpatient department project: Lessons and learning one year • Production of detailed service attendance, production of business on…. (October 2009). specifications and business cases case for CR. • One project undertaking full Contact details procurement A major strength of NHS Improvement • New and innovative service models has been the ability to share expertise Linda Binder e.g. heart failure rehabilitation in and experiences across the different National Improvement Lead community workstreams which has clearly led to linda.binder@improvement.nhs.uk • Increase in numbers undertaking greater productivity and quality rehabilitation outcomes benefiting other aspects of Professor Patrick Doherty • Improved equity of access NHS service delivery. This has placed National Clinical Lead • Reduced waiting times for CR CR in the driving seat for steering P.Doherty@yorksj.ac.uk • Clinical pathway development to national initiatives such as tariff ensure uptake of rehabilitation for implementation and commissioning. Dr Jane Flint, PPCI patients National Clinical Advisor • Economies of scale by integration “Now is not a time for standing still Jane.Flint@dgoh.nhs.uk with national heart failure, cardiac rather it is time to invest in NHS surgery and PPCI programmes. Improvement and engage with Julie Harries Director Many of the outcomes from the the quality and productivity Julie.harries@improvement.nhs.uk projects meet the quality, innovation agenda. I believe CR is one of the and productivity (QIPP) agenda. These best quality and productivity cases www.improvement.nhs.uk/ include: around and that the CR priority heart/cardiacrehabilitation projects has the appropriate focus QUALITY - (Safety) Centralised referral and skills to deliver service and patient tracking, standardised protocols and procedures, risk redesign, innovative commissioning stratification forms, governance and improved quality”. standards, skills competency Professor Patrick Doherty assessment, service specifications National Clinical Lead NHS Improvement
  • 22. 22 | Continuing to Improve Cardiac Services NHS Improvement System What is it? Where can I see a The NHS Improvement System is a demonstration of the system? comprehensive, online tool to support Demonstrations of some of the key sharing of quality service improvement modules are available on the resources in NHS services. Giving you improvement system home page at: direct access to useful information and www.improvement.nhs.uk/ stories from around the country, it will improvementsystem assist you in your own service improvement work. Who can use the system? The system is free of charge and can be Why use it? used by all staff working for NHS The NHS Improvement System actively organisations in England. helps organisations to effectively achieve their objectives in line with How can I register to use the World Class Commissioning. It enables system? users to be more strategic and align Access to the system is controlled long-term goals that can help to deliver by user ID and password. high quality, patient focussed health outcomes. To request an ID contact support@improvement.nhs.uk Which specialties are included? The system can be used to support sustainable service improvement in any specialty. What does it contain? • Service improvement tools and resources • Practical guidance • Case studies • Useful contacts • Signposting and links.
  • 23. Resources All the publications listed below Delivering the NHS Health Check: A National Priority Projects 2007/08 are available to download at: Practical Guide to Point of Care Summary Documents www.improvement.nhs.uk/ Testing Summary documents from the Heart publications Identifies some of the pros and cons to Improvement Programme’s 2007/08 the use of Point of Care Testing (POCT) national priority projects: as well as practical ‘solutions’ and • Making Best Use of Inpatient Beds A guide to commissioning learning from the field (November • Atrial Fibrillation in Primary Care cardiac surgical services 2009). • 18 Weeks Whole Pathways Eight NHS Trusts supported by their • 18 Weeks - Focus on Cardiac local cardiac networks were involved as Heart Failure - A quick guide to Diagnostics. demonstration sites during 2008/09 in quality commissioning across the the Cardiac Surgery National Priority whole pathway of care Guidance on Risk Assessment Project. Lessons drawn from these sites This practical guide sets out to help and Stroke Prevention for Atrial are outlined in the publication 'A Guide commissioners develop integrated heart Fibrillation (GRASP-AF) Tool to Commissioning Cardiac Surgical failure services by highlighting evidence This tool should be used as part Services' (March 2010). based practice and measurable of a systematic approach to the outcomes. It draws on the NICE identification, diagnosis and optimal Cardiac Rehabilitation - National Commissioning Guidelines (Feb 2008), management of patients with AF Priority Projects: Lessons and Our NHS Our Future (specifically long to reduce their risk of stroke. learning one year on... term conditions, urgent care and end www.improvement.nhs.uk/graspaf Cardiac rehabilitation (CR) is a national of life). (September 2008). priority project of NHS Improvement Using Discovery Interviews focusing on increasing the access to, Atrial fibrillation in primary care: to improve care equity of provision and uptake of CR making an impact on stroke www.improvement.nhs.uk/ services for heart attack, angioplasty prevention discoveryinterviews and CABG patients. The project This document aims to capture the final summaries include issues to be summary of their individual approach, Improving Cardiac Patient addressed, baseline position, actions lessons learned, improvements to Pathways: The Sustainability taken, key learning, QIPP outcomes and practice and quality outcomes, also Toolkit results to date from the 11 projects sharing tools and resources developed www.improvement.nhs.uk/ participating in this work (October to enable other health communities to heart/sustainability 2009). drive this agenda forward (October 2009). The Cardiac Data Dashbord A Guide to Implementing www.improvement.nhs.uk/ Primary Angioplasty Commissioning for Stroke heart/dashboard Since the publication of new national Prevention in Primary Care: the role good practice guidance on treatment of Atrial Fibrillation of heart attack, NHS Improvement has Developed following a national looked at the major issues and consensus meeting of opinion leaders obstacles to implementing primary in the field, this document is to develop percutaneous coronary angioplasty a concerted strategy towards the (PPCI) services across England and all management of AF in primary care, in the learning has now been pulled particular anticoagulant management together in a useful implementation and its significance in relation to guide (June 2009). reduction in the risk of stroke (June 2009).
  • 24. CANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk ©NHS Improvement 2010 | All Rights Reserved | March 2010 Delivering tomorrow’s improvement agenda for the NHS